<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">
    <div class="form-group hide">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_id" data-rule="required" data-source="presentation/index" class="form-control selectpage form-control" name="row[presentation_id]" type="text" value="{$row.presentation_id}">
        </div>
    </div>


    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Patient_name_or_initials')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-patient_name_or_initials" class="form-control form-control" name="row[patient_name_or_initials]" type="text" value="{$row.patient_name_or_initials}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Gp_medical_record_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-gp_medical_record_number" class="form-control form-control" name="row[gp_medical_record_number]" type="text" value="{$row.gp_medical_record_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Specialist_record_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-specialist_record_number" class="form-control form-control" name="row[specialist_record_number]" type="text" value="{$row.specialist_record_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Hospital_record_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-hospital_record_number" class="form-control form-control" name="row[hospital_record_number]" type="text" value="{$row.hospital_record_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Investigation_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-investigation_number" class="form-control form-control" name="row[investigation_number]" type="text" value="{$row.investigation_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Body_weight_kg')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-body_weight_kg" class="form-control form-control" name="row[body_weight_kg]" type="number" value="{$row.body_weight_kg}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Height_cm')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-height_cm" class="form-control form-control" name="row[height_cm]" type="number" value="{$row.height_cm}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Sex')}:</label>
        <div class="col-xs-12 col-sm-8">

            <select  id="c-sex" class="form-control selectpicker" name="row[sex]">
                {foreach name="sexList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.sex"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Last_menstrual_period_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-last_menstrual_period_date" class="form-control datetimepicker form-control" data-date-format="YYYY-MM-DD" data-use-current="true" name="row[last_menstrual_period_date]" type="text" value="{$row.last_menstrual_period_date}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Reaction_event')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-reaction_event" class="form-control form-control" name="row[reaction_event]" type="text" value="{$row.reaction_event}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Concomitant_therapies')}:</label>
        <div class="col-xs-12 col-sm-8">

            <select  id="c-concomitant_therapies" class="form-control selectpicker" name="row[concomitant_therapies]">
                {foreach name="concomitantTherapiesList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.concomitant_therapies"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Date_of_death')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-date_of_death" class="form-control datetimepicker form-control" data-date-format="YYYY-MM-DD" data-use-current="true" name="row[date_of_death]" type="text" value="{$row.date_of_death}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Was_autopsy_done')}:</label>
        <div class="col-xs-12 col-sm-8">
            <select  id="c-was_autopsy_done" class="form-control selectpicker" name="row[was_autopsy_done]">
                {foreach name="wasAutopsyDoneList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.was_autopsy_done"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">年龄信息:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar2" class="toolbar">
                <a href="javascript:;" data-number="2" data-title="年龄信息" data-href="/admin/presentationpatientcharageinfomation/add?cid={$row.id}"
                   class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 年龄信息</a>
                <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}" ><i class="fa fa-refresh"></i> </a>
            </div>
            <table id="table2" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
            </table>
        </div>
    </div>

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">相关病史:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar3" class="toolbar">
                <a href="javascript:;" data-number="3" data-title="相关病史" data-href="/admin/presentationpatientcharmedicalistory/add?cid={$row.id}"
                   id="presentationpatientcharmedicalistory" class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 相关病史</a>
                <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}" ><i class="fa fa-refresh"></i> </a>
            </div>
            <table id="table3" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
            </table>
        </div>
    </div>


    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">用药史:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar4" class="toolbar">
                <a href="javascript:;" data-number="4" data-title="用药史" data-href="/admin/presentationpatientchardrughistory/add?cid={$row.id}"
                   id="presentationpatientchardrughistory" class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 用药史</a>
                <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}" ><i class="fa fa-refresh"></i> </a>
            </div>
            <table id="table4" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
            </table>
        </div>
    </div>


    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">报告的死因:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar5" class="toolbar">
            <a href="javascript:;" data-number="5" data-title="报告的死因" data-href="/admin/presentationpatientcharreporteddeath/add?cid={$row.id}"
               id="presentationpatientcharreporteddeath" class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 报告的死因</a>
                <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}" ><i class="fa fa-refresh"></i> </a>
            </div>
                <table id="table5" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
                </table>
        </div>
    </div>


    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">确定的死因:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar6" class="toolbar">

            <a href="javascript:;" data-number="6" data-title="确定的死因" data-href="/admin/presentationpatientchardetermineddeath/add?cid={$row.id}"
               id="presentationpatientchardetermineddeath" class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 确定的死因</a>
            <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}" ><i class="fa fa-refresh"></i> </a>
            </div>
                <table id="table6" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
                </table>
        </div>
    </div>


    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">关于父母的信息:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar7" class="toolbar">
                <a href="javascript:;" data-number="7" data-title="关于父母的信息"
                   data-href="/admin/presentationpatientcharparentinformation/add?cid={$row.id}"
                   id="presentationpatientcharparentinformation" class="btn btn-success infomaition" title="添加"><i
                        class="fa fa-plus"></i> 关于父母的信息</a>
                <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}"><i
                        class="fa fa-refresh"></i> </a>
            </div>
            <table id="table7" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
            </table>
        </div>
    </div>


    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">父母的相关病史及并发疾病:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar8" class="toolbar">
            <a href="javascript:;" data-number="8" data-title="父母的相关病史及并发疾病"  data-href="/admin/presentationpatientcharparentconditions/add?cid={$row.id}"
               id="presentationpatientcharparentconditions" class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 父母的相关病史及并发疾病</a>
            <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}"><i
                        class="fa fa-refresh"></i> </a>
            </div>
                <table id="table8" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
                </table>
        </div>
    </div>


    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">父母的相关既往药物史:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar9" class="toolbar">
            <a href="javascript:;" data-number="9" data-title="父母的相关既往药物史"  data-href="/admin/presentationpatientcharparentdrughistory/add?cid={$row.id}"
               id="presentationpatientcharparentdrughistory" class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 父母的相关既往药物史</a>
            <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}"><i
                    class="fa fa-refresh"></i>
            </a>
        </div>
                <table id="table9" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
                </table>

        </div>
    </div>



    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
